Most people are expected to recover quickly and completely after sustaining a single, uncomplicated concussion. When unexpected difficulties are apparent or recovery is not progressing as expected, a neuropsychological evaluation may help to clarify the injury and noninjury variables that could be serving to prolong recovery. Interventions tailored to the needs of a specific patient can then be implemented to assist in improving functioning and minimizing distress.
Key points
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Because the etiology of persistent symptoms after concussion is often complex and multifactorial, neuropsychologists are well-positioned to understand and help manage such symptomatology.
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When unexpected difficulties are apparent or recovery is not progressing as expected, neuropsychological evaluation can help to identify factors serving to prolong recovery.
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After neuropsychological evaluation, interventions specifically tailored to address factors that may be prolonging recovery can help to improve functioning and minimize distress.
Introduction
Although most people recover quickly and completely after a single, uncomplicated mild traumatic brain injury (TBI) or concussion, a minority of patients experience persistent postconcussive symptoms. The etiology of such symptomatology is often complex and multifactorial, involving both injury and noninjury factors. Neuropsychologists, who have expertise in development, psychology, and brain injury, are well-positioned to understand and help manage such symptomatology. As such, neuropsychological evaluation is now widely recognized as an important component in the clinical management of individuals who sustain concussive injuries.
Introduction
Although most people recover quickly and completely after a single, uncomplicated mild traumatic brain injury (TBI) or concussion, a minority of patients experience persistent postconcussive symptoms. The etiology of such symptomatology is often complex and multifactorial, involving both injury and noninjury factors. Neuropsychologists, who have expertise in development, psychology, and brain injury, are well-positioned to understand and help manage such symptomatology. As such, neuropsychological evaluation is now widely recognized as an important component in the clinical management of individuals who sustain concussive injuries.
Natural clinical history
To manage any clinical condition, a clear understanding of its natural clinical history is imperative. Methodologically sound studies have now converged to paint a picture of what can be considered the “typical” recovery after concussion. In the first hours to days after injury, the neurobehavioral effects can be impressive, with pronounced postconcussive symptomatology reported, as well as changes apparent on objective cognitive and balance tests. Problems are typically self-limiting and resolve gradually for the majority of individuals in the initial days to weeks. When using objective performance-based tests, most methodologically rigorous studies fail to identify significant differences between concussed and control groups within 7 to 10 days in high school athletes and older athletes and within 2 to 3 months in nonathlete children and adults. In contrast, when examining outcomes using subjectively reported symptoms, a minority of patients display more persistent problems.
Risk factors for prolonged recovery
Both injury and noninjury factors have been found to play a role in persistent symptomatology. In general, injury-related variables (ie, the direct neurologic effects of concussion) account for more variance in the first weeks after the injury, and non–injury-related variables account for more variance in subsequent periods. One factor that has been found to increase the risk of persistent problems is more severe mild TBI, such as injury characterized by intracranial pathology or need for hospitalization. However, the effect of injury-related factors tends to diminish over time, and many “postconcussive” symptoms are not driven by injury-related neurologic factors.
One set of non–injury-related variables that account for persistent problems after concussion are personality factors, including how an individual responds to stressful events. Specific personality traits and coping strategies can affect how one might understand and respond to a concussive injury. In both adults and children, ineffective coping can serve to maintain symptoms and make one vulnerable to a prolonged recovery.
Many patients expect that they will experience postconcussive symptoms and will have prolonged symptoms after an injury occurs, a phenomenon characterized by Mittenberg and colleagues as “expectation as etiology.” This expectation of negative outcome then results in errors of attribution with regard to benign symptoms and events. For example, a simple lapse of attention may be attributed to the effects of a concussion, while disregarding preinjury functioning or normal inattention. Therefore, in some cases, it is the expectation that symptoms will be prolonged that causes the prolonged recovery.
The “good old days” bias has been recognized as another factor that influences symptom report after concussion. Patients and caregivers may underestimate the level of past concerns and attribute any current concerns to the injury. This bias has been well-demonstrated in adults and was recently found in many parents of children after concussion.
Preexisting behavioral and learning problems, family functioning, and caregiver adjustment have been all been shown to contribute additionally to the variance in rates of recovery and in the prediction of symptom outcomes. Comorbidities, such as posttraumatic stress disorder, pain, and mood problems, are also important to identify because the effects of these disorders can mimic postconcussive symptoms. Lower levels of education and female gender have been shown to be associated with increased symptom reporting as well.
Although “brain rest” has been widely recommended in recent years as a cornerstone of concussion management, recent studies have suggested that rest, particularly prolonged rest, may in fact exacerbate postconcussive symptoms and serve to prolong recovery. Prolonged rest may result in increased anxiety and negative expectations for recovery, depression with withdrawal from typical daily activities, and physical deconditioning.
Another important factor influencing symptom presentation after concussion is whether a patient is exaggerating or feigning problems. Exaggeration or feigning of symptoms occurs much less frequently in sports-related populations than in the general population of mild TBI, because most athletes are motivated to recover and return to their sport. However, in children and adolescents referred for persistent symptoms, the rate of feigning is similar between athletes and nonathletes (around 17%–18% in previous studies of our clinic sample).
Relatedly, litigation status also has been shown to influence symptom presentation after concussion. Litigation was a less frequent occurrence in the context of sport-related concussion historically when compared with general mild TBI patient populations. However, there has been a recent proliferation of lawsuits related to concussion in professional sports and a subsequent increase in lawsuits at all levels of sport.
Considerations in clinical neuropsychological evaluations
Several factors should be considered when planning how to integrate neuropsychological assessment into the clinical management of concussion. Important considerations include determining whether baseline testing will be implemented, if computerized tests will be used, and how validity tests will be incorporated. Although an in-depth discussion of these issues is beyond the scope of this paper, a brief discussion is presented.
Baseline Testing
The use of baseline testing with athletes has become increasingly widespread in recent years. Cognitive testing within a “baseline” model involves evaluating athletes before a season begins and then repeating the same testing if a concussion occurs. Baseline testing has been promoted as an effective tool to assist in determining when a person has made a complete recovery and can safely return to play. At first blush, baseline testing has considerable intuitive appeal. However, a number of statistical problems (eg, poor test–retest reliability of commonly used measures) exist. Moreover, at present, no identified empirical data are available to demonstrate that baseline cognitive testing actually improves clinical outcomes or reduces any known risk associated with concussive injury. Owing to the lack of clear evidence regarding the clinical utility of baseline testing, the most recent guidelines from the Zurich Concussion in Sport Conference concluded that there is insufficient evidence to recommend the widespread routine use of baseline testing, although neuropsychological testing was recognized as important in some cases.
Computerized Testing
Computerized tests are most often used because of the practical advantages of test administration. However, the practical appeal of computerized tests should not dictate adoption, because psychometric and testing expertise are important when considering whether or not to incorporate computerized cognitive tests into a concussion management plan. A critical appreciation of the psychometric properties of a test is crucial, because poor test–retest reliability and poor sensitivity and specificity have been reported for many computerized tests, as discussed. Inadequate understanding of the psychometrics (and the natural clinical history of concussion) increases the risks for both false-positive errors (ie, classifying someone as impaired when she or he is not) and false-negative errors (ie, classifying someone as intact when she or he is not). Because many factors can contribute to neuropsychological test performance, it is not sufficient to simply administer a test and interpret the results in isolation. No computerized test is diagnostic for concussion, and test results need to be interpreted by an examiner qualified to consider all potential contributing factors in understanding test results. This includes an understanding of neuropsychological concepts, psychometrics, test interpretation in the context of history and other data, and the dynamic biopsychosocial context in which postconcussive symptoms can occur.
Validity Testing
Understanding symptoms as neurologically based or related to nonneurologic or noninjury factors has clear implications for clinical decision making and management. As mentioned, an important factor that influences symptom presentation and neuropsychological test results is whether a patient is exaggerating symptomatology, exerting insufficient effort, and/or feigning. Multiple studies of both children and adults have shown that these are not uncommon occurrences in the context of persistent postconcussive symptomatology, with base rates ranging from about 15% to 20% in pediatric clinical settings to 40% to 50% or more in adult compensation-seeking settings. If an examinee exerts insufficient effort or intentionally performs poorly on a neuropsychological examination, the broader test results and self-report should not be considered valid.
Performance validity is assessed by the use of stand-alone and embedded tests that are designed to seem difficult but in actuality are quite easy and can be performed well with very little effort or ability. Multiple studies have demonstrated that performance on these tests is unrelated to pain, neurologic status, and cognitive abilities, except in the most extreme cases. Therefore, when patients perform poorly on these tests, a nonneurologic or non–injury-related explanation for the low scores is likely. Evaluating validity in clinical practice and addressing concerns for invalid test performance with patients and families is addressed in detail elsewhere.
Timeline for neuropsychological evaluation
McCrea and colleagues examined various metaanalytic studies on the natural clinical history of concussion. Based on this analysis, the authors defined 3 time points in recovery: the acute period (from the time of injury to approximately 5 days after the injury), the subacute period (from approximately 5–30 days after the injury), and a chronic period (when symptoms persist beyond 30 days). Most patients can be expected to be symptomatic in the acute period, and patients are typically managed medically during this period. A brief cognitive screening has been found to be as sensitive to sport-related concussion as lengthier testing in the acute period, and can be useful in guiding management decisions soon after injury. Several instruments have been developed for this purpose, with the Standardized Assessment of Concussion being one of the most commonly used in sport settings. Because most people recover relatively quickly after concussion, more comprehensive neuropsychological evaluation is typically not indicated during the acute period.
In the face of persistent problems during the subacute period, a relatively abbreviated neuropsychological evaluation could be appropriate, one that is more extensive than a very brief cognitive screening, but less extensive than a traditional neuropsychological assessment. This is likely justifiable and cost effective, because it can help to identify reasons for problems, assist in the creation of an appropriate clinical management plan, and reduce the risk of prolonged patient distress or secondary psychosocial problems.
Because most studies have concluded that measurable neurocognitive deficits completely resolve within a matter of days to weeks after concussion, some might question the role of neuropsychological assessment in the chronic period. However, for those patients who have apparently not returned to their baseline level of functioning, a neuropsychological evaluation is likely worthwhile, to assist in identifying factors that may be producing problems, to ensure accurate diagnostic decisions have been made, and to help develop an appropriate clinical management plan. We recently completed a prospective, quasiexperimental study examining the value of neuropsychological evaluation during the chronic period and found evidence for substantially reduced postconcussive symptomatology after such consultation, supporting the common clinical practice of referring for neuropsychological consultation in the face of persistent symptoms.
Components of neuropsychological evaluation
The following discussion is an adaption of a pediatric concussion neuropsychological management model proposed by Kirkwood and colleagues. When conducting a neuropsychological evaluation, the neuropsychologist must first obtain a detailed injury history to establish that the patient did indeed suffer a concussion. Because concussion does not produce a diagnostically distinct cognitive or symptom profile, the diagnosis of concussion or determination of injury severity can never be based solely on neuropsychological testing or symptom ratings. Therefore, the collection of injury-related information continues to be essential through interview and, whenever possible, objective records (eg, day of injury emergency transport or hospital records). In reviewing these data, careful consideration needs to be given to information that can be used to determine injury severity specifically. Injuries associated with a Glasgow Coma Scale score of lower than 13, neuroimaging abnormalities, a period of unconsciousness longer than 15 to 30 minutes, or posttraumatic amnesia longer than 24 hours could all suggest a more serious TBI, for which persistent problems might not be unexpected.
More comprehensive developmental, psychological/psychosocial, and educational/work information should also be gathered through interviews and objective records, to better understand the patient’s preinjury functioning and to identify any factors that could be influencing postinjury presentation and neuropsychological test results (eg, premorbid attention or learning problems, psychiatric issues, family or work stressors). Because family factors can impact concussion recovery, family stressors and functioning should additionally be considered. Last, the patient and family’s own expected course of recovery and litigation status need to be explored, because expectations and selective attentional biases after injury can have important effects on the concussion recovery process, as discussed.
Assessment Instruments
It is reasonable to include a measure of postconcussive symptomatology in any postconcussion neuropsychological workup given that concussion has large effects on symptom experience acutely. At the same time, the fact that “postconcussive” symptoms are nonspecific and can occur for innumerable reasons other than concussion must be kept in mind. Assessment of performance within select cognitive domains will also be important. In general, processing speed and aspects of memory, attention, and executive functioning have demonstrated the most sensitivity to the effects of concussion. Multiple batteries have been developed to examine these and related domains including both computerized and paper-and-pencil measures. Regardless of the instruments that are deemed most suitable for evaluating concussion effects, the results must be interpreted in the context of methodologically rigorous outcome studies demonstrating that the effects of concussion are typically small after the acute period and transient, as well as the technical weaknesses of the chosen instruments and limitations of using an abbreviated battery or test of any kind.
To facilitate proper interpretation, the postacute neuropsychological battery also should include coverage of domains that are likely to be insensitive to concussion. Most well-established or crystallized skills (eg, single word reading) should remain relatively preserved, even in the acute period after concussion. If performance on these measures is poor, consideration needs to be given to whether preinjury problems or other non–injury-related factors may be contributing to the findings.
To examine the contribution of psychological difficulties, personality or behavioral adjustment rating scales should be incorporated into the evaluation as well. Posttraumatic anxiety, pain, and sleep disturbance also need to be explicitly considered, because these are often associated with events that produce concussion (eg, motor vehicle collision). Studies with both adults and children suggest that these problems can affect neuropsychological and symptom presentation independent of the concussion. During the chronic stage, broader based coverage of neurocognitive, psychosocial, and achievement functioning may be indicated, to allow for a complete picture of the patient’s functional status and to help identify difficulties that may be contributing to persistent problems.
Neuropsychological Management Recommendations
Because there are a multitude of reasons patients may still be having difficulties months to years after a concussion, no generic management plan or treatment protocol is appropriate for all patients. Management recommendations need to be individually tailored and coordinated with other involved health care providers. Recommendations often include educational/work place accommodations soon after injury and other psychological/supportive approaches that help to address the individual’s associated conditions as identified in the neuropsychological evaluation. Continuing to provide education and reassurance is also appropriate months after injury, as is ensuring that reasonable attributions about the cause of symptoms have been developed. Patients and parents often underestimate their premorbid problems and thus can place too much emphasis on injury-related factors as the cause of their current symptoms. Finally, minimal evidence exists that injury-focused therapies, such as cognitive remediation, are effective for concussion management. In fact, injury-focused therapies may result in iatrogenesis in certain situations (eg, cases with a significant somatization component) and could serve to prolong recovery.
Return to Play
Although medical personnel ultimately decide on the safety of permitting participation in sports and other physical activity in most cases, the neuropsychological evaluation can assist in helping sort out the likely etiology of persistent symptoms to help guide return to play decisions. Activity restriction itself can have adverse effects on both mood and lifestyle, so athletes should be monitored closely when they are restricted from play. Should concerns arise, referral to a sports psychologist or other behavioral health professional could be warranted. In the end, the return to play decision should rest on a careful, individualized, cost–benefit analysis weighing the potential risks of a return to sports with the psychosocial and other benefits of allowing a return to play.
Pediatric Considerations
Soon after a pediatric concussion, school personnel should be notified of the injury, what to generally expect, the need to monitor the student for at least some days, and how best to support the student’s recovery when the student comes back to school. This typically includes temporary and informal accommodations to help ensure children are supported adequately soon after injury. At the same time, students should be encouraged to return to school in a timely fashion, most often in a few days, given the potential iatrogenic effect removal from school can have. A number of resources have been developed for school personnel to help optimize this balance between proper understanding/support and reassurance and timely resumption of school activities (eg, Children’s Hospital Colorado Return to Learn Program).
In the context of persistent symptoms in the chronic phase, coordinating school-based supportive services with educators is often necessary. Whether supports are needed from an academic or psychosocial perspective (or both), documenting them in some type of informal or formal educational plan may be indicated (eg, 504 Plan). The nature of the educational plan will depend largely on the neuropsychological evaluation results, including a detailed characterization of the student’s difficulties and an accurate determination of their likely etiology. Because concussion does not typically result in lasting academic problems, the educational plan should focus on the more likely non–injury-related etiology of the identified problems.
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